Looking Back, Moving Forward

At a Glance

Paul Singh explores two of the most important studies in glaucoma research in 2018, dealing with the role of corneal hysteresis as a risk factor for developing glaucoma, and with DARC, a new technology used for quantification of apoptosing cells

2018 saw the approval of several MIGS devices, including the iStent Inject, Hydrus microstent and the iStar MINIject

Approval and commercialization of new medications and drug delivery systems has considerably changed the landscape in 2018.

As a glaucoma specialist, I’ve really enjoyed seeing the significant advancement and proliferation of technology over the last few years, both in diagnostics and treatment. And 2018 was no exception. We have seen approvals for new topical glaucoma medications, approvals of new MIGS devices, and recent publications demonstrating new technologies that make it easier to identify glaucoma patients much earlier in the disease.

Over the last few years, there has been an emphasis on earlier detection – and understanding which patients are higher risk of glaucoma progression. A landmark 2018 study looked at the role of corneal hysteresis (CH) as a risk factor for developing glaucoma. (1) With increasing age, both the cornea and the lamina become more rigid and less resilient. The Reichert ocular response analyzer (ORA) (Ametek Reichert Technologies, Depew, NY, USA) measures CH and has been associated with progressive visual field worsening in glaucoma patients. Though earlier studies have demonstrated the link between low CH, glaucoma and response to topical medications, I consider the paper by Carolina Susanna and colleagues to be a landmark study as it is one of the first prospective and longitudinal studies to support the role of CH as a risk factor for developing glaucoma. In our clinical practice, we often use CH to help decide i) if we should initiate treatment in a glaucoma suspect, and ii) how aggressive the treatment should be, regardless of disease severity; after all, the study showed that lower CH measurements were significantly associated with increased risk of developing glaucomatous visual field defects over time.

Along the lines of earlier detection of glaucomatous optic neuropathy, another article published in 2018 caught my attention (2). Glaucoma patients are often diagnosed and treated when irreversible loss of visual function has occurred. Early detection – and therefore appropriate early treatment – are clearly best for such patients. A novel technology called Detection of Apoptosing Retinal Cells (DARC) allows real-time in vivo quantification of apoptosing cells through the use of a fluorescent biomarker and a confocal scanning ophthalmoscope. A recent Phase I clinical trial evaluated the safety of DARC and its ability to detect retinal apoptosis in glaucoma patients and healthy volunteers. Results demonstrate the potential benefits of DARC in the early detection of glaucoma.

In more detail, DARC uses an intravenous injection of an infrared fluorescently labeled ANX (ANX776), followed by retinal imaging using specific wavelengths with the use of a commercially available confocal scanning laser ophthalmoscope (cSLO) and indocyanine green angiography settings. In the Phase I trial, half of the enrolled subjects were eight healthy volunteers and the other half were eight patients with progressive glaucoma. Although the trial was designed primarily to assess the safety and tolerability of ANX776 in patients, it showed that the DARC count was significantly increased in glaucoma patients, compared with healthy volunteers. Furthermore, the DARC count correlated with increasing rates of glaucomatous progression. Phase II trials are underway.

Drug delivery has been a hot topic in the last few years. Three approvals in the cataract surgery space this year have spurred excitement among my colleagues.

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